How to Recognize the Symptoms of Eating Disorders and Get Diagnosed
Eating disorders are life-threatening conditions that affect each individual uniquely. As defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), eating disorders are psychiatric illnesses that influence thoughts and behaviors related to feeding patterns and self-perceptions.
Visibly malnourished bodies seem to warrant such a diagnosis, but thinking that is the only clue to an eating disorder is a harmful fallacy. In reality, eating disorders do not impact any one specific demographic, and anyone can develop one of these ailments.
Of all eating disorders, anorexia nervosa, bulimia nervosa and binge eating disorder (BED) are the most prevalent.
These disorders have a negative impact on physical and psychological health and can be fatal if they are left uncontrolled. Imbalances stemming from malnutrition lead to biopsychosocial effects, and as a result, eating disorders affect every aspect of life.
Sometimes those effects come in less obvious ways. For example, biological changes combined with poor self-worth reduce the potential for functional relationships and optimal sexual health. These effects cause irreversible damage to the brain and hormonal homeostasis, and may even affect the ability to start a family in the future.
Common symptoms of eating disorders
Eating disorders present themselves in many different ways, some more prominent than others. Typically, emotional and behavioral symptoms occur first. Someone doesn't usually descend into a full-blown eating disorder-caused medical crisis overnight.
Loved ones may notice personality and mood changes, a lack of desire for intimate connections and a reluctance to engage in enjoyable activities. Many of these changes overlap among the disorders, and recognizing them leads to the best possible prognosis.
A preoccupation with food, eating and/or weight, namely, changes in quantity, quality and frequency, are hallmarks of any eating disorder.
People may engage in food rituals, such as eating only specific foods or food groups, rearranging food on tableware, chewing excessively or going on various diets. A sense of shame and embarrassment may cause reluctance to eat around others—a cause of secretive eating in bulimia nervosa and binge eating disorder—or the avoidance of food altogether in anorexia nervosa.
People can become asocial and develop rigid lifestyles that exclude others, often at the expense of relationships. Some common symptoms among anorexia, bulimia and BED include:
- Frequently checking your body
- Wearing baggy clothes
- Complaining about being overweight (regardless of actual size)
- Establishing inflexible schedules to make time for disordered eating behaviors, such as binge and purge sessions and/or exercise regimens
In people with bulimia and binge eating disorder, an overabundance of empty wrappers and containers lying around, disturbances in eating patterns (e.g., unestablished meal times, bouts of fasting or extreme dieting) and weight fluctuations are common warning signs.
People with bulimia often exhibit purging behaviors, such as recurrent trips to the bathroom after meals, using laxatives or diuretics, and overexercising after eating.
Unlike bulimia and BED, anorexia symptoms originate in food avoidance or restriction, which is why weight loss and the inability to maintain a healthy weight are some of the first symptoms. People may have endless excuses to avoid eating, such as stomach pain or not feeling hungry; rigid thinking patterns; and a preoccupation with weight and/or size that has a strong impact on feelings of self-worth.
Diagnosis and testing
To receive a diagnosis, the person's eating disorder must interfere with their quality of everyday life. This means the behaviors impact relationships, education, work and physical health to the point of dysfunction.
"I think the folks who more humbly diagnose these things are therapists or psychiatrists, and then primary care providers," said Johnny Williamson, M.D., a Chicago-area psychiatrist who practices virtually with the eating disorder treatment program Alsana. "In primary care, I include an OB-GYN because they impact our fertility and sexual health, which is sometimes the route by which it becomes clear that there's a physiological impact of these patterns."
These professionals are qualified to perform in-person verbal and physical evaluations, along with administering questionnaires such as the Eating Attitudes Test (EAT-26) or Eating Disorder Examination Questionnaire (EDE-Q) to determine if someone is suffering from an eating disorder.
Diagnoses are reflections of current patterns of disordered eating and can be fluid, according to Williamson. In other words, someone with anorexia could eventually develop bulimia. For minors, sessions with caregivers and teachers validate symptomatic behaviors and other changes.
Along with the initial diagnosis, the DSM-5 specifies the level of condition severity. Body mass index (BMI), a measure of body fat based on height and weight, is used to signify progression of anorexia. While the low end of the "normal" BMI is 18.5, people with mild anorexia have a BMI at or above 17.
After mild, the ranges are moderate (16 to 16.99 BMI), severe (15 to 15.99) and extreme (less than 15). A BMI of less than 15 is often deadly, and people within this category are at risk of developing end-stage anorexia.
The severity of bulimia or binge eating disorder is determined by the number of symptomatic episodes per week, also using mild, moderate, severe and extreme as categories.
Mild bulimia is defined as one to three episodes per week of inappropriate compensatory behaviors, such as vomiting or using laxatives or diuretics. Moderate is four to seven episodes per week, severe is eight to 13, and extreme is 14 or more. BED follows the same severity scale ranges, but instead of compensatory behaviors, it uses binge eating episodes.
When to seek help and who to see
Like most conditions, early intervention is best, but eating disorders are tricky due to both personal and professional barriers.
"Eating disorders thrive in secrecy and can often be associated with a sense of shame that can get in the way of seeking help," said Henry Cheng, M.D., a psychiatrist and the regional medical director of The Renfrew Center of New York in New York City. "It is important not to try to tackle the problem alone. Unfortunately, not all therapists or medical clinicians are knowledgeable about eating disorders."
Having a competent multidisciplinary team approach to address various impairments is important, according to Cheng, Williamson and Molly Perlman, M.D., MPH, CEDS, chief medical officer of Monte Nido & Affiliates, based in Miami, and a member of the board of directors of the Eating Disorders Coalition.
Among Williamson's aforementioned healthcare professionals—therapists, psychiatrists, primary care physicians, OB-GYNs—Perlman recommended having at least one who can address psychiatric comorbidities, which are extremely common.
The experts also mentioned getting a dietitian who specializes in eating disorders to assist with meal planning and nutritional rehabilitation. A knowledgeable dietitian is a vital member of the team.
Depending on symptom severity, they recommended seeing a PCP or psychiatrist first, but the key is to seek help promptly after symptoms become apparent.
What happens if eating disorders go undiagnosed?
When eating disorders remain undetected, physical and mental health get progressively worse. Though people have varying thresholds for health complications, eventually, they are inevitable and could result in death.
"Eating disorders can impact everything from physical health to mood to social and occupational functioning," Cheng said. "It is important to have a thorough evaluation in order to coordinate resources and make an appropriate treatment plan."
Unfortunately, males are prone to underdiagnosis due to stigma and shame, despite making up one-third of the eating disorder population. In fact, men couldn't even be officially diagnosed with anorexia until the latest DSM-5 release because they were unable to experience amenorrhea (absence of menstruation).
The very same stigma and shame make women reluctant to admit they have a problem and seek help, too. This is further evidence of the need for trained professionals equipped to recognize warning signs.
Myths and misconceptions surrounding eating disorders
Despite their high prevalence, eating disorders are widely misunderstood.
One of the most common misconceptions is that eating disorders are demographic-specific, even though they can occur in anyone.
"It's not just a skinny white woman's disease. It's all genders, all races, all body types," Perlman said. "That right there just kind of explains part of the problem of making people aware of eating disorders."
These conditions are occurring in people at younger ages, with the earliest reports of anorexia starting in kindergarten years.
Another fallacy is the idea of eating disorders being a choice, which couldn't be further from the truth. They are multifaceted psychiatric conditions stemming from various biopsychosocial factors, many of which are out of a person's control.
Eating disorders are not about food; they are a way to endure life when it's all too much. A person often views their body as the only thing under their control. There is no specific body type for eating disorders, as people can experience malnutrition and be consumed by disordered thinking at any weight. Appearances do not always accurately reflect the eating disorder severity.
Don't let an eating disorder take over your life. If you can't talk to a family member or a friend, talk to a professional. Without a regular therapist, taking that first step can be difficult. Giddy telehealth takes the difficulty out of such a search, providing access to hundreds of healthcare professionals who offer video visits as a regular part of their practices. It is an easy-to-use online portal whose therapists and physicians have expertise across the full scope of medical care. Many have same-day appointments.